Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep.

You are in a high risk group for insomnia. Sleep problems are more common in women than men, increase with age, and are aggravated by menopause. The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits. Unfortunately, if you still have your uterus you have to take some progesterone. There are options like long acting intrauterine forms of progesterone that can minimize side-effects. I am totally opposed to oral estradiol such as Estrace. http://test.askdrjones.com/2007/04/28/say-goodbye-to-the-pill-ladies/

Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form. The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect. I recommend that you don’t take synthetic progesterone like Provera.

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off. If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep. The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours. Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough. The generic form is probably weaker. The CR form is not as strong as the tablets for inducing sleep but lasts longer. Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem. Morning bright light and or evening melatonin or prescription Rozerum may also help.

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful. Trazodone, Seroquel, or low dose Doxepin may help. Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations. It is harder to treat initially and gets easier as fear of insomnia subsides. When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem. It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you. Don’t give up until you find the right medication at the right dose.